Disability Benefits Name* First Last Social Security Income (SSI) AmountSocial Security Disability (SSD) AmountHow much income could you receive and still retain your benefits?How much income would you need to give up your benefits?Do you have any pending applications or claims for SSI or SSD?YesNoIf yes, please describe briefly.Do you have a WIPA counselor?YesNoDo you have a payee?YesNoIf yes, please enter name of payee.Are you enrolled in Medicare?YesNoAre you enrolled in Medicaid?YesNoDo you receive food stamps?YesNoIf yes, what amount?Are you claimed as a dependent on someone else's income tax return?YesNoMy Hope Services Vocational Specialist* Δ Return to Enrollment Forms
